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Five priority areas identified for systemic child death reform

  • The Child Death Review Board’s Annual Report 2022–23 has been released, providing insights into the 60 cases reviewed this year.
  • The board conducts system reviews following the deaths of children who were known to Child Safety in the 12 months prior to their deaths. It identifies opportunities for systemic improvements to legislation, policies and practices that are required to reduce the likelihood of preventable deaths and better keep children safe.
  • The board has identified five key areas where more action is needed, relating to home schooling, youth justice, First Nations research, child safety practice in cases of parental methamphetamine use, and coercion and parental deception in cases of domestic and family violence.

The death of any child is a tragedy and has a lasting impact on families, friends and the broader community. The board extends its deepest sympathies to those who have lost a child, and it respects the dedication of workers and professionals who are involved in these cases.

Of the 60 child deaths reviewed by the board in the past year, 24 were from natural causes and 26 were from external causes, including drowning, suicide, fatal assault or neglect, non-intentional injury and transport-related deaths.

Concerningly, almost half of all deaths were of children younger than one year, and Aboriginal and Torres Strait Islander children continue to be over-represented. These are reoccurring trends that do not appear to be improving.

This year, the board also looked at the commonalities across all cases reviewed since the board’s inception in 2020, finding four common characteristics: presence of domestic and family violence, methamphetamine use, housing instability, and family court involvement. Domestic and family violence was prevalent in almost 70 per cent of cases and methamphetamine use in almost 33 per cent of cases.

These findings led the board to look further into the effectiveness of child safety risk assessments involving parents who use substances, as well as opportunities to better arm practitioners to identify and respond to parental deception and coercive control that affects children in cases of domestic and family violence.

The board identified five priority areas and made six recommendations to prevent child deaths, centred around improving visibility of at-risk children, reframing our view of the youth justice system, prioritising First Nations research, and strengthening child safety practices.

To achieve whole-of-system improvements to prevent child deaths, the board recommended:

  • assessing the safety of children who are registered for home education
  • reappraising the response to youth crime and the purpose of youth justice
  • improving research on the needs of First Nations communities
  • strengthening child safety practice in response to parental substance and methamphetamine use
  • increasing system visibility of children and young people in the context of coercion and parental deception.

The annual report features summaries of some of the cases reviewed, including timelines of children’s lives that show their interactions with various systems prior to their deaths. These timelines provide insights into gaps in service delivery and about how the system needs to change to better protect and support vulnerable children and families.

The annual report can be viewed at

Quotes attributed to Child Death Review Board Chairperson Luke Twyford:

“All Queensland children deserve to be loved, respected and have their rights upheld.

“This is true regardless of a child’s living circumstances or upbringing, and the work of the board tells me there’s more to be done to protect Queensland children, especially those who become involved in the child protection system.

“Queensland’s Child Death Review Board seeks to honour the lives of children and young people by conducting respectful reviews aimed at preventing future loss of life.

“The annual report outlines the lives of 60 young Queenslanders who have died, including detailed, de-identified case studies that highlight the child’s touchpoints with government agencies and support services prior to their death.

“The board has identified five areas for whole-of-government improvements and made six recommendations that will lead to action that avoids preventable child deaths.

“When implemented, these recommendations will improve the visibility of at-risk children and will strengthen the safeguards in place that are designed to protect them.

“I would like to acknowledge the workers and professionals who were involved with the children and families, whose contributions are immensely important to bolstering the safety nets for vulnerable children and families.”

[ENDS] 15 March 2024

Media Contact:

Child Death Review Board – Kirstine O’Donnell ph: 0404 971 164